Initial experience with hemostatic fibrin glue as adjuvant during tubeless percutaneous nephrolithotomy.

PURPOSE: To report our initial experience with hemostatic fibrin glue as an adjuvant during tubeless percutaneous nephrolithotomy (PCNL). PATIENTS AND METHODS: Seventeen consecutive patients underwent tubeless PCNL with injection of 2 mL of Tisseel Vapor Heated Sealant (Baxter AG, Vienna, Austria) into the percutaneous tracts at the conclusion of the procedure. The perioperative outcomes of these patients were compared retrospectively with those of a control group of 25 consecutive patients who underwent tubeless PCNL without the use of fibrin glue. The safety and efficacy of the new approach was evaluated by comparing operative time, hemoglobin drop, transfusion requirement, length of hospitalization, postoperative pain, analgesic use, and postoperative complications in the two groups. RESULTS: There was no difference in the mean drop in hemoglobin, transfusion requirement, or complications in the two groups. However, patients undergoing Tisseel tubeless PCNL required less analgesia postoperatively (P=0.05), and they were discharged an average of 7 hours earlier than the patients in the control group. There were no major postoperative complications. CONCLUSIONS: Use of fibrin glue was safe and was associated with less analgesic requirement and a shorter hospital stay. Randomized studies are needed to evaluate its clinical role in the future.

Evaluation of fluid absorption during holmium laser enucleation of prostate by breath ethanol technique.

PURPOSE: In a prospective manner we studied various factors affecting fluid absorption during HoLEP. We also simultaneously evaluated changes in serum electrolytes and hemoglobin decrease during HoLEP. MATERIALS AND METHODS: This prospective study comprised of 53 patients who underwent HoLEP at our institute. Irrigation fluid was normal saline tagged with ethanol (1% w/v). Intraoperatively a standard breath analyzer was used to monitor expired breath ethanol levels during the procedure at 10-minute intervals. Patients who absorbed irrigating fluid as indicated by positive intraoperative breath tests were considered absorbers. Serum electrolyte and hemoglobin estimations were done before and after surgery. Total irrigation time, amount of irrigation fluid used, weight of resected tissue and presence of capsular perforation were recorded. Statistical analysis was performed to observe the effects of various factors on the amount of intraoperative fluid absorption. RESULTS: Of 53 patients studied 14 (26.41%) demonstrated fluid absorption in the range of 213 to 930 ml (mean 459). Preoperative prostate weight, total irrigation time, amount of irrigation fluid used and resected tissue weight were all significantly greater in absorbers. Similarly, absorbers had a statistically significant decrease in hemoglobin level postoperatively. There was no statistically significant change in serum electrolytes between absorbers and nonabsorbers. CONCLUSIONS: Preoperative weight of prostate, total irrigation time, amount of irrigation fluid used and weight of resected tissue all directly influence the amount of fluid absorption during HoLEP. There is no significant change in serum electrolytes and no risk of the transurethral resection syndrome.

Safety and efficacy of bilateral simultaneous tubeless percutaneous nephrolithotomy.

OBJECTIVES: To evaluate the feasibility and safety of bilateral simultaneous tubeless percutaneous nephrolithotomy (PCNL). METHODS: From August 2004 to January 2005, 10 patients underwent bilateral simultaneous tubeless PCNL. Patients needing more than two percutaneous tracts, having significant intraoperative bleeding, or a residual stone burden were excluded from the study group. The outcome of these 10 patients was compared with a control group of 10 patients who had previously undergone bilateral simultaneous PCNL with routine placement of a nephrostomy tube. RESULTS: The two groups had comparable demographic data, except for a greater stone burden in the right renal units in patients undergoing standard PCNL. The study and control groups needed a total of 22 and 23 tracts, respectively. The difference in the mean drop in hemoglobin, transfusion requirement, and complication rate between the two groups was not statistically significant. Patients undergoing tubeless PCNL required less analgesia (P = 0.001) and were discharged 20 hours earlier (40 versus 60 hours) than those in the control group. However, the difference in mean hospital stay was not statistically significant owing to the small sample size. Complete stone clearance was achieved in 80% of the renal units in the study group and 75% of the renal units in the control group. Three renal units in the tubeless group and four in the standard PCNL group had less than 5-mm residual fragments. CONCLUSIONS: Bilateral simultaneous tubeless PCNL appears to be a feasible, safe, and effective procedure offering potential advantages of decreased analgesic requirement and hospital stay without increasing the complications. Additional clinical studies with a larger number of patients are required to confirm these potential benefits.

Tubeless percutaneous nephrolithotomy: a prospective feasibility study and review of previous reports.

OBJECTIVE: To evaluate the status of tubeless percutaneous nephrolithotomy (PCNL) in managing renal and upper ureteric calculi, from initial experience and a review of previous reports. PATIENTS AND METHODS: From September 2004 to December 2004, 46 patients were scheduled for tubeless PCNL in a prospective study. Patients with solitary kidney, or undergoing bilateral simultaneous PCNL or requiring a supracostal access were also enrolled. Patients needing more than three percutaneous access tracts, or with significant bleeding or a significant residual stone burden necessitating a staged second-look nephroscopy were excluded. At the end of the procedure, a JJ ureteric stent was placed antegradely and a nephrostomy tube avoided. The patients' demographic data, the outcomes during and after surgery, complications, success rate, and stent-related morbidity were analysed. Previous reports were reviewed to evaluate the current status of tubeless PCNL. RESULTS: Of the 46 patients initially considered only 40 (45 renal units) were assessed. The mean stone size in these patients was 33 mm and 23 patients had multiple stones. Three patients had a serum creatinine level of >2 mg/dL (>177 micromol/L). Five patients had successful bilateral simultaneous tubeless PCNL. In all, 51 tracts were required in 45 renal units, 30 of which were supracostal. The mean decrease in haemoglobin was 1.2 g/dL and two patients required a blood transfusion after PCNL. There was no urine leakage or formation of urinoma after surgery, and no major chest complications in patients requiring a supracostal access tract, except for one with hydrothorax, managed conservatively. The mean hospital stay was 26 h and analgesic requirement 40.6 mg of diclofenac. Stones were completely cleared in 87% of renal units and 9% had residual fragments of < 5 mm. Two patients required extracorporeal lithotripsy for residual calculi. In all, 30% of patients had bothersome stent-related symptoms and 60% needed analgesics and/or antispasmodics to treat them. CONCLUSION: Tubeless PCNL was safe and effective even in patients with a solitary kidney, or with three renal access tracts or supracostal access, or with deranged renal values and in those requiring bilateral simultaneous PCNL. The literature review suggested a need for prospective, randomized studies to evaluate the role of fibrin sealant and/or cauterization of the nephrostomy tract in tubeless PCNL.